It started in New York City. At the height of the first wave of COVID-19 in March 2020, New Yorkers applauded daily at windows, on balconies and in the streets to thank doctors, nurses, paramedics and others for their tireless efforts to fight the pandemic. Cities in France, Italy, Spain, the United Kingdom and other countries quickly followed their example. Residents stood at the window every evening in the lockdown, joining their neighbours from across the street in clapping hands together for all the people whose work had suddenly become vital to survival, central to the functioning of our societies, and who were on duty day and night despite high risks of infection. With vulnerable older people at highest risk of dying from COVID-19, managing caregiving both in long-term care (LTC) institutions and in people’s homes became a huge challenge for LTC staff, whose working conditions and pay became a focus of public discussions and policy debate.

Now that the pandemic-related stress has subsided, where do we stand? Paying respect to LTC and other essential workers was clearly very important, but it needs to be followed with concrete action. LTC workers continue to work under difficult conditions, with low pay, and little social recognition despite the applause from the balconies and despite the fact that LTC supply and working conditions have been on policy makers’ radar for years.

Urgent action is needed. Rapid population ageing in OECD countries will greatly increase the demand for workers in long-term care (LTC) services. In order to meet this demand for formal care, the share of LTC workers in total employment will need to increase by about 30% over the next decade. But fewer workers may be available and willing to take on these jobs, which are often underpaid, performed in difficult working conditions, and overall not well recognised by societies.

LTC workers are among the lowest paid and earn less than those working with similar qualifications in the healthcare sector. Low wages are one of the reasons for the difficulty to attract workers in LTC. In addition, shift work is common in LTC, and associated with a wide range of health risks, such as anxiety, burn-out and depression. Other mental risk factors are becoming more common as well, such as stressful behaviour, in particular aggression, from care recipients. Close to two-thirds of LTC workers are also exposed to physical risks, as they move, transfer and reposition patients.

Given the high demand for LTC staff and insufficient supply one could expect wages and working conditions to improve in order to attract more workers into the sector. But this is not happening. Why this is the case and what can policy makers do about it?

A range of factors can explain why wages have not been rising and why working conditions remain unattractive. One of them is the lack of collective bargaining in LTC. Care workers are hard to reach for unions, since they often do not work in a common physical location, but rather scattered across many workplaces. At the same time, identifying the employer counterpart in order to negotiate can be difficult due to the fragmentation of home care workers. Another important factor is that the bulk of LTC is still provided by informal carers. Families often cannot afford to pay for more expensive LTC and, if they cannot find low-paid care, either provide care themselves or resort to undeclared work.

Governments trying to address the LTC workforce’s challenges therefore need to design comprehensive strategies. While the exact design of such a strategy will depend on how the LTC sector works in each country, all countries share the need to reform policies in a series of areas, that will promote and can be summarised as more RESPECT for the caring profession:

  • Recognise, both economically and socially, care workers

  • Enforce (effective regulations) governing the LTC sector

  • Sustainably fund the LTC sector

  • Pay better salaries

  • Equip workers with new technologies

  • Collective bargaining for better work conditions

  • Train to retain LTC workers

If LTC continues to be perceived as a dead-end street staff shortages will persist and reach socially unacceptable levels. More public spending will be required in many countries to help match supply and rising demand but that alone will not be enough. Implementing the RESPECT strategy will go a long way to make the LTC sector more attractive and do right by people who are supporting families with care for their loved ones. Respect means far more than applauding on balconies.

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